The effectiveness of wet-cupping for nonspecific low back pain in Iran: a randomized controlled trial.
ABSTRACT To determine the efficacy of wet-cupping for treating persistent nonspecific low back pain.
Wet-cupping therapy is one of the oldest known medical techniques. It is still used in several contemporary societies. Very minimal empirical study has been conducted on its efficacy.
Randomized controlled trial with two parallel groups. Patients in the experimental group were offered the option of referral to the wet-cupping service; all accepted that option. The control group received usual care.
Medical clinic in Kermanshah, Iran.
In total, 98 patients aged 17-68 years with nonspecific low back pain; 48 were randomly assigned to experimental group and 50 to the control group.
Patients in the experimental group were prescribed a series of three staged wet-cupping treatments, placed at 3 days intervals (i.e., 0, 3, and 6 days). Patients in the control group received usual care from their general practitioner.
Three outcomes assessed at baseline and again 3 months following intervention: the McGill Present Pain Index, Oswestry Pain Disability Index, and the Medication Quantification Scale.
Wet-cupping care was associated with clinically significant improvement at 3-month follow-up. The experimental group who received wet-cupping care had significantly lower levels of pain intensity ([95% confidence interval (CI) 1.72-2.60] mean difference=2.17, p<0.01), pain-related disability (95% CI=11.18-18.82, means difference=14.99, p<0.01), and medication use (95% CI=3.60-9.50, mean difference=6.55, p<0.01) than the control group. The differences in all three measures were maintained after controlling for age, gender, and duration of lower back pain in regression models (p<0.01).
Traditional wet-cupping care delivered in a primary care setting was safe and acceptable to patients with nonspecific low back pain. Wet-cupping care was significantly more effective in reducing bodily pain than usual care at 3-month follow-up.
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ABSTRACT: Traditional Persian medicine is based on humoral medical concepts. In the case of abundant blood in the body, tabi'at (body nature) deals with this imbalance by elimination of the morbid substances via some controlling mechanisms. If tabi'at could not react properly, the physician should prescribe an intervention to let the extra blood out. This can be done through phlebotomy, wet cupping, and the use of leech or scarification of the ears. Cupping with scarification may eliminate the morbid substance through the scarified skin, and cupping without scarification evacuates the morbid materials from the compromised organs. Wet cupping in health state is meant to be applied for preventing the blood humor dominance in susceptible individuals. In disease condition, wet cupping is defined as a treatment in which the patients confront the abundance of blood. Wet cupping may have harmful complications in extremely thin or obese patients. Wet cupping should be postponed in patients compromised by diseases especially in the thick phlegm abundance. In Asia, Iranian people, because of religious beliefs, are very interested in cupping therapy. Many unsupervised cupping procedures are performed in Iran, whereas benefits and risks of these procedures are undetermined by providers and clients. In this study, the most important indications and contraindications of wet cupping have been reviewed based on the traditional Persian medicine resources.Journal of evidence-based complementary & alternative medicine. 02/2014;
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ABSTRACT: Abstract Urticaria is a kind of skin rash that sometimes caused by allergic reactions. Acute viral infection, stress, pressure, exercise and sunlight are some other causes of urticaria. However, chronic urticaria and angioedema could be either idiopathic or caused by autoimmune reaction. It lasts more than six weeks and could last a very long time. It is thought that the level of C-reactive protein CRP increases in patients with chronic urticaria and the level of Erythrocyte sedimentation rates (ESR) decreases. Thirty four patients with chronic or recurrent urticaria were treated with wet cupping. Six of these patients had a history of recent infection/cold urticaria, therefore, they were eliminated and the remaining 28 were chosen for this study. ESR and CRP were measured in these patients aged 21-59, 12 females and 16 males, ranged from 5-24 mm/h for ESR with a median 11 mm/h and 3.3-31.2 mg/L with a median of 11.95 mg/L for CRP before and after phlebotomy (250-450mL.) which was performed as a control for wet cupping therapy. Three weeks after phlebotomy, wet cupping was performed on the back of these patients between two shoulders and the level of ESR and CRP were measured again three weeks after wet cupping. The changes were observed in the level of CRP and ESR after phlebotomy was negligible. However, the level of CRP with a median 11.95 before wet cupping, dramatically dropped to1.1. The level ESR also with a median 11 before wet cupping rose to 15.5 after wet cupping therapy. The clear correlation between the urticaria/angioedema and the rise of CRP was observed as it is expected. No recurrence has been observed on twenty five of these patients and three of them are still recovering from the lesions.Bentham Science Publishers. 05/2013;
- Pain Medicine 04/2014; · 2.46 Impact Factor
Complementary Therapies in Medicine (2009) 17, 9—15
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/ctim
The effectiveness of wet-cupping for nonspecific low
back pain in Iran: A randomized controlled trial
Khosro Farhadia, David C. Schwebelb, Morteza Saebc, Mansour Choubsaza,
Reza Mohammadid, Alireza Ahmadia,∗
aDepartment of Anesthesiology, Critical Care and Pain Management, Pain research center,
Kermanshah University of Medical Sciences, Iran
bUniversity of Alabama at Birmingham, USA
cDepartment of Orthopedic Surgery, Kermanshah University of Medical Science, Iran
dKarolinska Institute, Stockholm, Sweden
Available online 24 June 2008
Low back pain;
Objectives: To determine the efficacy of wet-cupping for treating persistent nonspecific low
Background: Wet-cupping therapy is one of the oldest known medical techniques. It is still used
in several contemporary societies. Very minimal empirical study has been conducted on its
Design: Randomized controlled trial with two parallel groups. Patients in the experimental
group were offered the option of referral to the wet-cupping service; all accepted that option.
The control group received usual care.
Setting: Medical clinic in Kermanshah, Iran.
Participants: In total, 98 patients aged 17—68 years with nonspecific low back pain; 48 were
randomly assigned to experimental group and 50 to the control group.
Intervention: Patients in the experimental group were prescribed a series of three staged wet-
cupping treatments, placed at 3 days intervals (i.e., 0, 3, and 6 days). Patients in the control
group received usual care from their general practitioner.
Main outcome measures: Three outcomes assessed at baseline and again 3 months following
intervention: the McGill Present Pain Index, Oswestry Pain Disability Index, and the Medication
Results: Wet-cupping care was associated with clinically significant improvement at 3-month
follow-up. The experimental group who received wet-cupping care had significantly lower lev-
els of pain intensity ([95% confidence interval (CI) 1.72—2.60] mean difference=2.17, p<0.01),
pain-related disability (95% CI=11.18—18.82, means difference=14.99, p<0.01), and medi-
cation use (95% CI=3.60—9.50, mean difference=6.55, p<0.01) than the control group. The
differences in all three measures were maintained after controlling for age, gender, and dura-
tion of lower back pain in regression models (p<0.01).
∗Corresponding author at: Department of Anesthesiology, Critical Care and Pain Management, Kermanshah University of Medical
Sciences, Bolvar Shahid Beheshti, Kermanshah 6718818838, Iran. Tel.: +98 831 7240890; fax: +98 831 8360016.
E-mail address: firstname.lastname@example.org (A. Ahmadi).
0965-2299/$ — see front matter © 2008 Elsevier Ltd. All rights reserved.
10K. Farhadi et al.
acceptable to patients with nonspecific low back pain. Wet-cupping care was significantly more
effective in reducing bodily pain than usual care at 3-month follow-up.
© 2008 Elsevier Ltd. All rights reserved.
Traditional wet-cupping care delivered in a primary care setting was safe and
Low back pain (LBP) is among the most debilitating, most
expensive, and most common complaints patients raise
during routine physical examinations worldwide.1,2It is
widespread in many countries, and is associated with sub-
stantial financial costs and loss of quality of life. For
example, the World Health Organization reports that LBP
affects over 80% of people at some point in their life, and
from 4 to 33% of a population at any one time.3Data from
specific nations support these data. In Canada, Finland and
the United States, more people are disabled from work-
ing as a result of back pain than from any other group of
diseases.4Over 60% of Americans, 40% of the adult pop-
ulation in Britain, and 62% of adults in African countries,
are reported to experience low back pain at some point in
their lives, and between 10 and 30% of populations in these
nations suffer from chronic low back pain at any point of
In Iran, where the present study was conducted, the lim-
ited data available suggest the prevalence of LBP in Iranians
who work in industry and in Iranian school-age children were
21 and 17.4%, respectively.7,8
Western medicine typically treats low back pain with
a combination of physical therapy; activity modification
and rest; pain-relieving and anti-inflammatory medications;
and, in extreme cases, surgery. These treatment options
demonstrate mixed efficacy and success. In many cases,
an acceptable amount of pain is relieved through typical
Western medical treatment techniques. However, in other
cases some pain remains; in some cases, typical Western
treatments are completely ineffective.9
Wet-cupping is an ancient medical technique, with doc-
umented use dating to several ancient cultures10—13and
contemporary practice in many parts of the European
and Eastern world, including Iran. Application of the wet-
cupping technique itself is rather straightforward. A glass
cup is applied to the skin, and a partial vacuum created
inside the cup. After a few minutes, superficial incisions are
made to the skin, and bloodletting induced through replace-
ment of the cup with vacuum. This process is repeated a few
Despite use in Iranian (and other) cultures both histori-
cally and today, the effectiveness of wet-cupping to treat
nonspecific low back pain is unknown. We implemented
a randomized controlled trial comparing two treatments
design to test the efficacy of wet-cupping to treat continu-
ous referrals for nonspecific low back pain in an outpatient
care clinic in Iran. Three outcome measures were used: pain
intensity, medications used, and pain-related disabilities in
function. We hypothesized the group randomly assigned to
wet-cupping treatment would have less pain, would use
fewer medications, and would report fewer pain-related dis-
abilities following treatment compared to a ‘‘usual care’’
Sample size, study design and participants
Nonspecific low back pain has been characterized as an
‘‘intermittent, recurrent, episodic problem’’ and includes
four type of pain: local, referred, radicular, and that aris-
ing from secondary (protective) muscular spasm.14,15The
study used a two-group randomized controlled trial design
to treat nonspecific low back pain. Patients in the experi-
mental group received wet-cupping treatment. Patients in
the control group received usual care, which consisted of
a combination of medication and physician-recommended
A priori power calculations, allowing for a 10—15%
dropout rate, indicated that 16 patients were needed in
each group to detect a difference in outcome between the
effect size of d=0.61 based on pilot research indicating a
mean change of 2.71 points at 3 months (S.D. 4.451) on the
Medication Quantification Scale.16This sample size was also
estimated to give a power of 90% to detect a difference of
0.68 points on the PPI scale of McGill Pain Questionnaire.17A
difference of 1 point is generally considered to be clinically
significant on this scale.
We subsequently tripled the target number of recruited
patients to allow for between-wet-cupping effects to be
tested. We wanted to review the wet-cupping effect accord-
ing to ‘‘duration of LBP’’ and in patient who have ‘‘the
history of surgery for LBP’’.
Fig. 1 illustrates patient enrollment patterns. Identi-
fied patients included a total of 106 consecutively referred
patients diagnosed with nonspecific low back pain. Inclu-
sion criteria included: (a) lower back pain persisting for
4 weeks or more; (b) age 17—68 years; and (c) current
episode of low back pain having at least a 4-week duration.
Exclusion criteria included possible spinal pathology (e.g.,
disc prolapse, pending litigation (e.g., workplace injury),
bleeding disorders (e.g., hemophilia), and current treat-
ment with wet-cupping. Five patients were excluded due
to one or more of those criteria. Three other patients were
excluded because the back pain resolved before treatment
began. Ninety-eight patients were therefore included in the
trial. Patients were randomized to two groups in a double-
blind manner by the sealed opaque envelope technique.
Forty-eight were assigned to the wet-cupping treatment
condition, and fifty to the usual-care treatment (Fig. 1). All
Effectiveness of wet-cupping for nonspecific low back pain11
Patients progress through the trial: CONSORT flowchart.
protocols were approved by the Kermanshah University of
Medical Sciences (KUMS) Local Research Ethics Committee.
The wet-cupping technique
For ethical reasons, patients randomly assigned to the wet-
cupping treatment were offered the opportunity to refuse
consent to the research and accept usual treatment instead.
No patients accepted this option; all chose to receive the
wet-cupping treatment as assigned randomly. The treatment
itself was performed using standard techniques in Iranian
medical centers.18—20Vacuum cups with plastic vessels were
applied in three stages, as recommended in traditional Ira-
nian medicine for treatment of nonspecific lower back pain:
(a) between the two scapulas, opposite to T1—T3 Scapular
spine, in Phase 1 (day=0); (b) the sacrum area, between the
lumbar vertebrae and the coccyx bone, in Phase 2 (day=3);
and (c) the calf area, in the middle surface of gastrocnemius
muscle, in Phase 3 (day=6) (Fig. 2).18—20The size of vacuum
cup used was based on the size of the patients’ body (75
or 120cm3). We used primarily 120cm3, and occasionally
75cm3for the thinnest patients.
During the third stage, the calf area was treated based
on the lower back pain experienced. If the back pain was on
the back pain was double-sided, we treated both calf areas.
Each wet-cupping treatment procedure lasted about
20min and was conducted in five steps:
(1) Primary sucking: The cup is placed on the selected site
and the air inside the cup rarified via electrical suction
(or, rarely due to technical reasons, manual suction).
The cup clings to the skin and is left for a period of
(2) Scarification: Superficial incisions are made on the skin
using the ‘‘multiple superficial incisions’’ technique
‘‘multiple superficial incisions’’ technique, we applied
multiple superficial incisions. As a result, after healing
of the wound, the scar lesion does not remain.
(3) Bloodletting: The cup is placed back on the skin, using
the same manner described above, until it is filled
Anatomical areas of wet-cupping for low back pain.
12K. Farhadi et al.
group means (standard deviations)
Demographic profiles at baseline by allocation
Characteristic Intervention group
Duration of lower
8.3% yes10% yes
with blood from the capillary vessels. The volume of
blood varied across patients (e.g., it tended to be lower
in obese patients). Our experience is that treatment
effects are unrelated to the volume of blood. In fact,
the duration is more important than the blood volume
released. Each phase of wet-cupping was divided based
on a time period of 3—5min and re-scarification was not
(4) Removal: The cup is removed, and the process repeated
The ‘‘usual care’’ treatment
The ‘‘usual care’’ control group received the standard treat-
ment for low back pain in Iranian clinics. This treatment
included: (1) encouragement for early return to usual activ-
ities, excluding heavy manual labor, (2) activity alteration
to minimize symptoms, (3) acetaminophen, or NSAIDs, (4)
on patient preference), (5) bed rest—–not more than 2 days
(optional, based on patient preference), and (6), spinal
Basic demographic information was collected at baseline.
Three measures were used to assess pain, disability, and
functioning at both baseline and 3 months post-intervention:
the Medication Quantification Scale Version III (MQS),16
the Present Pain Intensity Scale (PPI) of the McGill Pain
Questionnaire,17and the Oswestry Pain Disability Index
The PPI is a standard and well-used index of current
pain. Patients rate their current pain on a 6-point scale
from ‘‘no pain’’ to ‘‘excruciating’’. The ODI is a measure
designed specifically to assess lower back pain. It includes
10 items that target various physical activities (e.g., lifting,
walking, sleeping) that are frequently painful for individu-
als with lower back pain. Each item is scored on a 6-point
scale, yielding a possible range of 0—60. The MQS is a quasi-
quantitative measure of the strength, dosage, and quantity
of pain medications used by patients. It has strong psycho-
Following descriptive analyses, the primary analyses were
conducted in two steps. First, we computed basic inde-
pendent samples t-tests comparing the intervention and
control groups on all three outcome measures (pain
intensity, pain-related disability, and medication). Sec-
ond, we computed three linear regressions, predicting
the three outcome measures based on group as well as
age, sex, duration of lower back pain, and previous back
As in most intervention research, there was a small
amount of missing data in this research due to patient loss
to follow-up. This study achieved a high follow-up rate
at 3 months (85 and 90% in the wet-cupping and usual
care groups, respectively). A comprehensive analysis of
the known characteristics of patients indicated that there
was no evidence of any difference between the randomly
assigned groups in those lost to follow-up. Consistent with
intention-to-treat principles, missing data from participants
who did not complete the trial were imputed using ‘‘the
mean of nearby points’’ techniques.
Table 1 illustrates baseline descriptive data for the inter-
vention and control subsamples. As shown, the control and
intervention groups were quite similar in age, sex, duration
groups and comparing both groups (two-tailed tests)
Means (standard deviations), Mean difference, 95% confidence interval (CI) and p-value for intervention and control
MeasureControl groupIntervention groupMean difference95% CI
Note: PPI=Present Pain Intensity Scale of the McGill Pain Questionnaire. ODI=Oswestry Pain Disability Index. MQS=Medication Quantifi-
Effectiveness of wet-cupping for nonspecific low back pain 13
Linear regression models predicting outcome change scores based on demographic, pain history, and group assignment
−0.01 to 0.02
−0.07 to 0.13
−0.05 to 0.05
Sex (1=male, 2=female)
−0.55 to 0.47
−2.72 to 3.52
−1.22 to 1.88
Duration of low back pain (per month)
0.01 to 0.10
0.01 to 0.06
0.01 to 0.30
Previous spinal surgery (1=y, 2=n)
−0.37 to 1.23
1.19 to 11.30
−1.20 to 3.70
Group (1=control, 2=intervention)
−2.63 to −1.73
−18.11 to −12.61
−6.94 to −4.20
Note: PPI=Present Pain Intensity Scale of the McGill Pain Questionnaire. ODI=Oswestry Pain Disability Index. MQS=Medication Quantification Scale. B=Unstandardized coefficients. For
PPI: F (5, 92)=22.6, p<0.01; for ODI: F (5, 92)=30.8, p<0.01; for MQS: F (5, 92)=16.0, p<0.01.
of pain, and previous surgeries. They also scored similarly
on all three baseline measures (see Table 2). Independent
samples t-tests comparing these differences were all non-
As shown in Table 2, the control and intervention groups
were vastly different (p<0.01) in their scores of pain inten-
sity, pain-related disability, and medication use 3 months
following the treatment. That is, the intervention group
reported strong declines in pain intensity, pain-related dis-
ability, and medication use during the post-intervention
assessment. The control group showed essentially no change
in pain intensity and pain-related disability, and only modest
change in medication use.
Table 3 illustrates the results of linear regression mod-
els predicting change in all three outcome measures from
baseline to follow-up. Note that change in scores (the dif-
ference between post-intervention and baseline) serves as
the dependent variable in these models; this score was
preferred over use of post-intervention scores because it
allows us to compensate for baseline levels of functioning.
As shown, group assignment was a significant and strong
predictor in all three models. Those individuals in the wet-
cupping intervention group reported less pain intensity, less
pain-related disability, and less medication use than those
in the usual care group. Duration of pain also emerged as
a predictor of the three outcomes in the linear regression
models, with better outcomes in individuals with a shorter
duration of pain. Finally, previous spinal surgery was a signif-
icant predictor of pain-related disability, with those patients
who had a history of surgery reporting more pain-related
Although wet-cupping has been used traditionally to
treat lower back pain in Iranian and other cultures for
centuries,19,20this study represents one of the first con-
trolled empirical tests of its efficacy. Results suggest that
patients in both the experimental and control groups
reported improvement, but the patients in the experimental
group, who received wet-cupping treatment, scored signifi-
cantly lower on measures of pain, disability, and medication
use than the patients who received only usual care. We
conclude that wet-cupping shows great promise as an effec-
tive treatment for nonspecific low back pain. These results
are congruent with those reported in an unpublished dis-
sertation testing the efficacy of wet-cupping on treating
lower back pain23and in published work testing the effi-
cacy of wet-cupping to reduce risk factors of heart disease,24
Brachialgia paraesthetica nocturna,25and migraine and ten-
The physiological mechanisms through which wet-
cupping might function remain unknown. It has been
suggested that the effects of wet-cupping can be divided
into several components, including neural, hematological,
immune and psychological effects18—26. In particular, the
‘‘pain suppression’’ mechanism of wet-cupping might be
through influence on three neurological systems: (a) the
‘‘analgesia’’ system in the brain and spinal cord (includ-
ing the periaqueductal gray and periventricular areas,
the Rapha magmus nucleus, and the Nucleus reticularis
14K. Farhadi et al.
paragigantocellularis); (b) the brain’s opiate system (endor-
phins and enkephalins), and (c) most influential, through
inhibition of pain transmission by simultaneous tactile sen-
sory signals.27Moreover, diffuse noxious inhibitory controls
(DNICs) might contribute partially to the pain-relieving
An alternative hypothesis, also plausible, is that wet-
cupping may function in a manner similar to acupuncture: it
may stimulate particular parts of the body that include the
release of neurotransmitters, endogenous opioid-like sub-
stances, and activation of c-fos within the central nervous
system.29Future research is needed on these topics.
Patients in our study experienced very minimal adverse
effects from the wet-cupping treatment. The most signifi-
cant side effect from wet-cupping therapy is fainting during
the wet-cupping (vaso-vagal shock). This was seen only in
younger patients (7% (n=3) of patients, all in the age 17—30
group), all of whom had no previous history of bloodlet-
ting or wet-cupping. To treat vaso-vagal shock, we asked
patients to sit or lie in bed for 5—10min. A second concern
about wet-cupping side effects is transmission of contagious
infections such as B and C HPV or HIV. Historically, this con-
cern arose from the fact that in ancient Persian traditional
medicine, a ram’s horn was used for wet-cupping and was
shared by many patients, causing high potential for trans-
mission of infectious disease. In contemporary society, of
course, we use sterile methods (sterile surgical blade and
disposable cup) and have no indication of infection in our
patients. Therefore, besides the three patients who expe-
rienced vaso-vagal shock, we have no evidence of adverse
effects during the research.
Strengths, limitations, and future directions
This research had several methodological strengths. The
sample was recruited directly from a primary care clinic.30
Follow-up rates were excellent, with 85% and 90% of
patients in the experimental and control groups, respec-
tively, providing data 3 months post-intervention. Despite
these strengths, the research also had limitations. One
prominent limitation was our choice of treatment for the
control group. Usual care commonly entailed a mixture med-
ication and recommended back exercises. Control patients
did not receive a sham wet-cupping intervention. We consid-
ered alternative options for the control group, but each had
limitations. Use of dry-cupping or acupuncture, for exam-
response as wet-cupping. Given the strength of our current
findings, future research might consider using dry-cupping,
acupuncture, or other complementary medicine techniques
in an RCT compared to wet-cupping treatment.
Critics might also be concerned about the possibility of
a placebo effect arising from wet-cupping treatment. We
emphasize that a placebo effect may not be a negative fac-
tor; if the cupping treatment is effective due partially to
nonspecific placebo effects, this should be viewed as a posi-
tive medical intervention. Cultural issues, including the long
tradition of using cupping in Iranian society, might enhance
placebo effects. Despite these facts, be believe the placebo
effect is not likely to be the primary mechanism behind the
efficacy of wet-cupping, largely because the control group
received an equivalent amount of attention and medical
Relatedly, critics might be concerned that the wet-
cupping treatment was efficacious not because of the
physiological action of suction and scarification, but rather
because of the psychological interactions between patient
and therapist during the treatment. We believe this unlikely
given the strength of our findings, but future research should
evaluate this issue.
A final limitation of the study is the fact that patients in
the trial were aware of their group assignment, which was
difficult to hide given the experimental design. This aware-
ness may have created biased assessments of patients’ LBP
scores. Most important, the difference between groups is
far larger (odds ratio for response=42.78, p<0.001, CI 95%
11.85—154.46) than empirical estimates of bias from failure
to blind (odds ratio 1.2).31Lack of bias is also implied by
similar results in research using wet-cupping to treat other
illnesses and medical conditions.18,24,25
Finally, our study was limited somewhat by the short
follow-up period. We were able to demonstrate the positive
effects of wet-cupping for 3 months, but long-term efficacy
remains to be tested.
Results from the present study suggest that wet-cupping is
care. No adverse effects were reported from subjects after
The authors would like to thank the patients who partici-
pated in this study. Financial support for this project was
provided by the Kermanshah University of Medical Sciences
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